The Contact Lens Practice, Birmingham, UK

Laser & Eye Surgery

Not always as good as the claims!

Contact Lens Practitioners and Optometrists

Tried before?

If you've already arranged an appointment for an assessment visit please complete the pre-consultation form at the bottom of the navigation bar.

Problems with your Last Lenses ?
Complete this form and our Contact Lens Practitioners will study it to
see if we feel we could be of assistance to you.

Please note the information that you give us will be kept in the strictest
confidence and will only be seen by the Professionals at the Contact Lens Practice

** Please do not click 'back' when you are filling out this questionnaire as all the
information that you have entered will be lost, and you will have to re-enter it. **

What type were you fitted with	other
Were they	other
If branded which were they	other

Were they Conventional wear, i.e. worn until they needed replacing

Yes

How often were they replaced

Were they

Date fitted | Month Year

Last worn

After the first pair fitted, were any changes made in power or fitting with this

type of lens

Yes

Was more than one 'Brand' or 'Type' of lens material fitted

Yes

What Brand of solution did you use

Any other Brands:

Were the solutions used changed

Yes

What brand did you try:

What was the maximum time you could wear them for. Hours

What was the name of the Optician/Practice where the Lenses were fitted? If more than one detail in order.

When was your last eye test for glasses. Months

My last spectacle was:
Please give details below

Sph

Cyl

Axis

Prism

Base

Sph

Cyl

Axis

Prism

Base

Distance

Near

Further Comments

My last Contact Lens Prescription was:

			Sph	Cyl	Axis
Right
	BCOR	DIAMETER
Left
			Sph	Cyl	Axis

What wearing difficulties did you experience:
Tick all that apply

Difficulty in bright light		Reduced Vision	Pain
Dryness		Discomfort	Red Eyes
Poor wearing times		Conjunctivitus
Handling Difficulty	Other

Do you suffer from any allergies?

Yes

Please give details:

Whilst wearing the lenses were you taking any prescribed medication or drugs?
(If yes please give details in the box below)

During the period you were wearing the lenses did you suffer any health problems, including, problems with teeth or sinuses or excessive weight loss or gain. (If yes please give details in the box below)

Any other information you think is of use to us.

Please enter your contact details so we can get in touch with you.

Title

Forename

Surname

Daytime Telephone

Evening Telephone

Post Code

Age Bracket

Would it be practical for you to visit our practice for consultations Yes No

Do you have any friends that you would like to introduce to the Contact Lens Practice.
If so enter there email address here:

Our Vision is Your Vision

Our Vision is to introduce our patients to the freedom and pleasures of life without glasses. Specialists for over 35 years we have the expertise to fit those others consider unfittable.